Chaos with Cannabis? How to diagnose and treat cannabis use disorder

Jake is a 28 yo man with a history of anxiety since adolescence who comes to you to establish care. He is generally healthy and uses cannabis every evening to “help calm down.” He started smoking heavily in high school. For the last decade, he has smoked one joint nightly. His partner doesn’t like his smoking, and he skips a night or two occasionally to avoid conflict with her. He is a bit shaky, irritable, and uncomfortable the nights he skips.

He struggles to find ways to distract himself on those “skip” nights, as he’s often thinking about when he’ll be able to smoke the next day. He says sometimes he needs to smoke more and for longer the night after he skips to help him relax and sleep.

You ask Jake: “What’s the role of cannabis in your life? How does it help (or not help) you? How does it affect aspects of your day to day?” Jake says work has been harder in the last few months—his concentration isn’t what it was 5 years ago. Jake says he spends less time with friends after work, as he usually wants to get home to smoke and relax. He thinks the biggest issue is that his partner feels like he prioritizes weed over her. He reflects, “I guess I crave it, and so that means I prioritize it.” 

You ask Jake: “What are your goals around cannabis?” Jake says he values his relationship and doesn’t want the weed to get in the way of it. His goal is to cut down his use and address what he’s feeling on his “skip days.” Jake also wonders if his anxiety is worse, but maybe he’s just worried about the “skip days” and his relationship. 

Jake asks if there’s a medication or anything else that can help him.
You then… 
A) Prescribe dronabinol as it’s an FDA approved medication for his cannabis issue
B) Recommend N-acetyl-cysteine given the evidence for adults trying to reduce cannabis use
C) Review the criteria for a diagnosis of cannabis use disorder with him
D) Discuss the role of CBT for both the anxiety and cannabis use
E) C+D

In answering this question, you remember that making the diagnosis of a substance use disorder (SUD) has a framework based on the Diagnostic and Statistical Manual of Mental Disorders–5 (DSM-5); you just can’t recall the individual components right now.

That’s okay because this is where breaking things down into chunks and mnemonics come in. The eleven DSM-5 criteria for SUDs can be separated neatly into four categories related to substance use: physical dependence (syndromes of withdrawal & tolerance), risky use, social problems, and impaired control. The below table* from McNeely and colleagues conveniently groups the 11 DSM diagnostic criteria into those 4 broader categories. 

To make a diagnosis of mild SUD in the context of appropriate medical treatment, a patient has to meet at least 2 DSM criteria, and those 2 cannot be withdrawal or tolerance. Those two entities are expected consequences of prescribed medical treatment (for example, what happens over time when patients take prescribed opioid medications). Meeting 2-3 DSM criteria is a mild SUD, 4-5 is moderate SUD, 6+ for severe SUD. The severity points to the role that the substance plays in a patient’s life.

As a patient-centered shortcut to figure out if a person has a SUD, or more specifically in Jake’s case, a cannabis use disorder (CUD), ask yourself if there is documented substance use and consequences of that use––meaning an impact or an effect on the patient’s life from their use. Examples of the impact on a patient’s life could include a person not being able to show up for important parts of their life (for example, missing work or a parent-teacher conference for a child because of hangovers), physical problems like an abscess from injection or mental health problems like new paranoid delusions. Substance use that has an impact on a person’s life is termed problematic or chaotic use. Many patients don’t identify with having a substance use disorder or the diagnostic term of SUD; instead, patients often connect that there’s a problem with their use or chaos in their life because of the substance use.

If you like mnemonics, look for the 4 R’s (Role failure, Relationship trouble, Risk of bodily harm, Repeated attempts to cut back) and 4 C’s ((loss of) Control, Craving, Compulsion to use, Consequences of use) in a patient’s history to make a SUD diagnosis. 

For Jake, he has described trouble at work and in his relationship related to the cannabis, difficulties cutting down on his own, cravings, compulsion, spending a lot of time using it, withdrawal, and tolerance; with these 7 items, he meets criteria for a severe CUD and in other words, a problematic pattern of cannabis use.

There is ongoing research into how to adapt the DSM criteria for CUD when patients are taking cannabis for therapeutic purposes. As with prescribed opioids for pain, tolerance and withdrawal should not be the primary basis for diagnosing CUD when the cannabis is consumed in a therapeutic context. This acknowledges the expected neuroadaptation to chronic cannabis exposure that’s aimed at addressing a chronic medical problem.

Jake asks about medications to help with cannabis use disorder. Unfortunately, we don’t have any FDA approved meds to treat CUD. There is limited data that gabapentin at doses of 1200mg/day may reduce cannabis use (Mason 2012). In a patient like Jake who has anxiety and trouble sleeping, trialing gabapentin may be hitting two birds with one (off-label) gabapentinoid. For more on the use of gabapentin in anxiety disorders, please see this previous PsychSnap. For adolescents (15-21yo), there is evidence for N-acetyl-cysteine (NAC; available OTC) 1,200mg twice daily in reducing cannabis use when used with contingency management (Gray 2012); the same positive results were NOT seen for adults, so NAC is not recommended as evidence-based treatment for adult patients like Jake.

The strongest signal for the treatment of cannabis use disorder in adults is with psychosocial interventions. Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET) are evidence-based treatments for CUD, as discussed in this Cochrane review (Gates 2016). These treatments explore the narratives patients tell themselves about their substance use, introduce and increase strength-based thinking, and promote healthy coping strategies. In Jake’s case, he shared that he started with cannabis initially to help with sleep and calming down; so if the cannabis is used by a patient to help anxiety and/or insomnia (the root cause of use), CBT is a better first-line treatment for both.


To answer our initial question: is there a medication or anything else that can help Jake with his cannabis use, the correct answer is E (options C+D, Review the criteria for a diagnosis of cannabis use disorder and Discuss the role of CBT for anxiety and cannabis). If individual CBT is not readily available, consider a trial of gabapentin or enrollment in other group therapy that includes contingency management programs (rewards offered for not using substances).

We will explore ways to apply harm reduction principles in a conversation around SUDs in a future PsychSnap. In the meantime, for more on CUD in an audio format, check out the 2022 Curbsiders Addiction Medicine podcast mini-series’ episode on CUD.


References

*table from: McNeely J, Adam A. Substance Use Screening and Risk Assessment in Adults. Baltimore (MD): Johns Hopkins University; 2020 Oct. Table 3, DSM-5 Diagnostic Criteria for Diagnosing and Classifying Substance Use Disorders: https://www.ncbi.nlm.nih.gov/books/NBK565474/table/nycgsubuse.tab9/# 

Mason BJ, Crean R, Goodell V, Light JM, Quello S, Shadan F, Buffkins K, Kyle M, Adusumalli M, Begovic A, Rao S. A proof-of-concept randomized controlled study of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis-dependent adults. Neuropsychopharmacology. 2012 Jun;37(7):1689-98. doi: 10.1038/npp.2012.14. Epub 2012 Feb 29. PMID: 22373942; PMCID: PMC3358737.

Gray KM, Carpenter MJ, Baker NL, DeSantis SM, Kryway E, Hartwell KJ, McRae-Clark AL, Brady KT. A double-blind randomized controlled trial of N-acetylcysteine in cannabis-dependent adolescents. Am J Psychiatry. 2012 Aug;169(8):805-12. doi: 10.1176/appi.ajp.2012.12010055. Erratum in: Am J Psychiatry. 2012 Aug 1;169(8):869. PMID: 22706327; PMCID: PMC3410961.

Gates PJ, Sabioni P, Copeland J, Le Foll B, Gowing L. Psychosocial interventions for cannabis use disorder. Cochrane Database Syst Rev. 2016 May 5;2016(5):CD005336. doi: 10.1002/14651858.CD005336.pub4. PMID: 27149547; PMCID: PMC4914383.


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